Appraising perception, accessibility and uptake of DAT among patients with TB

INTRODUCTION Poor adherence to TB treatment poses a significant public health threat to TB control programmes. The sustainability of directly observed treatment has been questioned because of its non-patient-centred approach and resource-intensive nature, and Digital Adherence Technologies (DATs) provide a suitable alternative. This study assessed the feasibility and acceptability of DATs among patients with TB. METHODS This descriptive study was conducted in eight states in Nigeria among all patients with drug-susceptible TB. RESULT A total of 230 patients (89.1%) own a phone that no one else uses, and 18 (7.0%) use a family phone. A higher proportion of 189 (73.3%) have airtime credit and 119 (46.1%) have internet credit on their phone. In addition, 216 (83.7%) stated that the reminders they received on their phone helped them remember to take their medicine. Only 11 (4.3%) patients missed a dose of the TB medicine. Equally, 11 (4.3%) patients had taken their TB medicine without using DAT. Of these, 7 (63.3%) did not use DATs because they forgot to text medication labels, and 3 (27.6%) did so because of poor network. Only four (1.6%) purchased additional items to support the use of DATs. CONCLUSION DATs are acceptable in a wide variety of settings, even with reported challenges. Implementation efforts should ensure access, address technical challenges, and minimise additional cost to patients.

T B, an infectious disease caused by Mycobacterium tuberculosis, is of public health importance and one of the top 10 deadliest infectious diseases worldwide. 1ong-term antibiotic treatment lasting for at least 6 months is needed to control TB infection and avoid disease spread. 2 Based on this, TB treatment is prone to non-adherence, resulting in treatment failure even when effective TB medication is available. 3In 2020, approximately 10.0 million people fell ill with TB and an estimated 1.5 million died globally. 4It is estimated that in Nigeria, 452,000 (295,000-641,000) persons fell ill with TB in 2020. 4At the end of 2019, the treatment coverage rate in Nigeria was 28%, and 71% of patients faced catastrophic costs. 5atient compliance is a key factor in the success of any treatment.Increased evidence has demonstrated that more engaged patients enjoy higher treatment adherence, better health outcomes, and better care experiences compared with those who are less engaged in their care. 6Non-compliance with TB treatment poses a significant public health threat, as it is associated with increase in transmission rates, morbidity, and costs to TB control programmes. 7It also leads to persistence, as well as resurgence of TB and is regarded as the chief cause of relapse and drug resistance. 8It is noteworthy that the interplay of factors determines TB treatment adherence and outcomes, including characteristics of the regimen, attitudes of service providers, and socioeconomic, cultural, and environmental factors. 9mproving treatment adherence is a key challenge in patients with TB.The sustainability of directly observed treatment (DOT) has been questioned because of its non-patient-centred approach and resource-intensive nature. 10,11As such, in many high TB burden settings, 15% or more of patients with TB do not complete treatment.This consequently can adversely affect the health and economic wellbeing of patients, caregivers, and health systems. 12,13he WHO has ensured adherence as a principal component of global 'End TB Strategy'. 13In furtherance to this, in April 2017, the WHO in its comprehensive update on guidelines for drug-susceptible TB treatment advised the use of digital adherence technologies (DATs) to improve adherence with evidencebased recommendations on the use of electronic medication monitors to help patients adhere to TB medication. 14Critical to the successful use of such devices in improving patient medication adherence is the ability of providers and patients to effectively use the technology.To design and deploy an electronic monitoring device optimally, one must consider patient and provider acceptability, satisfaction, and feasibility. 14 recent real world randomised trial in Uganda involving DOT vs. DAT demonstrated that 99DOTS can be iteratively adapted to meet local user needs, effectively facilitate treatment adherence, and improve treatment success.15 99DOTS has been promoted as a low-cost, scalable intervention to help patients with TB adhere to treatment.15 Although it is expected that SMS, telephone calls and video directly observed therapy (VDOT) may replace in-person DOT, patients' ability to participate in these programmes depends on the patients place of residence, telecommunication infrastructure, phone availability and connection costs.14 DATs are increasingly being implemented as an alternative to traditional DOT for TB treatment.16 A study noted that TB patients acknowledged that SMS could serve as medication reminders to overcome forgetfulness and offers them the opportunity to familiarise oneself with medication adherence, especially among those who did not have experience taking medication regularly.17 However, to date there are limited data on their feasibility and acceptability among persons on treatment which this study aims to assess.16

Study area and setting
The study was carried out in 8 states in Nigeria, 4 in the North region (Benue, Kaduna, Kano and Nasarawa states) and 4 in the South regions (Akwa Ibom, Anambra, Imo and Rivers).These states combined show a treatment success rate of 90% and reflect a mix of TB burden and gaps in treatment success rate within the 14 states where KNCV Nigeria implements the TB LON Regions 1&2 Project.KNCV Nigeria, in collaboration with her technical partners, implemented 99DOTS and video-observed therapy (VOT) in 98 health facilities that provide DOTS across eight states.Patients enrolled on 99DOTS were required to text a unique hidden code on their medication labels to the country short-code 3340 as proxy confirmation of medication intake while VOT patients sent daily videos using a smart phone.Patients who failed to send videos or text messages were sent reminder messages by 6 pm daily and all adherence data were made available to the healthcare workers (HCWs) on an adherence platform for patient management.

Study population
All drug-susceptible TB patients on treatment at facilities in the eight (8) select states during the study period, who consent to participate in the DAT study and are enrolled on DAT at the start of their treatment.However, patients transferred to/from another facility to complete treatment and patients who already started treatment before enrolment on DAT were excluded.

Study design and duration
The study was a descriptive cross-sectional study using a questionnaire to assess patients' perception of accessibility and uptake of DATs among selected facilities.The study lasted for 3 months (October-December 2022)

Sample size determination and sampling techniques
All TB patients that presented in the health facilities in selected states were studied.

Data collection
Data was collected using a semi-structured questionnaire involving open-ended questions about the characteristics of patients, ownership of phones, access to network services, opinion on and acceptability of DATs.

Data analysis and presentation
Data was analysed using IBM SPSS v25 (IBM, Armonk, NY, USA).Categorical variables were summarised using proportion and percentages.They were presented in tables.

Ethical consideration
Ethical clearance was received from the National Health Research Ethics Committee (NHREC), Federal Ministry of Health, Abuja, Nigeria.The project obtained signed informed consent from patients and only non-identifying patient data were collected as part of the study.Voluntary participation and confidentiality were ensured.
Table 2 shows ownership, access and use of mobile phone of patients as well as ancillary expenses incurred in course of treatment for patients.The majority of them (n = 230, 89.1%) owned a phone that no one else used, while 18 (7.0%)used family phone of which they were not the primary owners.A higher proportion (n = 189, 73.3%) had airtime credit on their phone sometimes and 66 (25.6%) always.Moreover, a higher proportion (n = 119, 46.1%) had internet credit on their phone sometimes, and 41 (15.9%) always.Only 4 (1.6%) bought additional items to support the use of DAT.Items bought were phone credit/airtime (n = 3, 75.0%) and

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Perception, accessibility and uptake of DATs data or internet package (n = 1, 25.0%).Of these, 2 (50.0%) spend 500 Nigerian naira (NGN; equivalent to USD0.78) and 1 (25.0%)spent NGN 200 (USD0.31)and NGN 1,500 (USD2.35)each.Table 3 shows opinion on digital adherence technology (DAT) for patients.Out of all patients, 228 (88.3%) knew how to use DAT, 227 (88.0%) will recommend using DAT to their family or friends if they have TB, 220 (85.3%) agreed that the instructions on the DAT makes it easy for them to remember what to do, 216 (83.7%) stated that the reminders they receive on their phone help them to remember to take their medicine and 215 (83.3%) use DAT while taking TB medicines will help them get healthy.A higher proportion were equally positive on other opinion on DAT (all at least 62.5% and above).However, 64 (24.8%) said that it takes them too much time to record themselves taking their TB medicine, or text 3340 for the labels every day and 90 (34.9%) were worried that using the DAT will make them more likely that others will find out that they have TB.
When asked if they could change anything about the adherence technology, what they would change, about 143 (55.4%) would not change anything, 82 (31.8%) wanted to increase the frequency of reminders and 13 (5.0%)would use DAT for all their medications.Table 4 shows TB medication activities of patients and health workers' assistance/involvement for patients.Out of all patients, 180 (69.8%) use a mix of methods, 29 (11.2%)do not require reminder and 21 (8.1%) were from family member or friends.A higher proportion spends less than 1 minute to send a text to the number [3340] for those that use medication labels.Only 37 (14.3%) have been shown what their adherence information looks like (e.g., how many doses you have taken) by HCW.Those that responded to calls from health workers spent few minutes on the call.The majority have not been visited by health worker.
Table 5 displays the utilisation of adherence technology by patients, instances of missed doses of TB medication, and the responses of health workers to these occurrences.Only 11 individuals (4.3%) had ever taken their TB medicine without utilizing Directly Observed Treatment (DAT).Among these, 7 (63.3%)did not use DAT because they forgot to text medication labels, 3 (27.6%)due to poor network connection, and 1 (9.1%) because they lacked access to a phone.Approximately 63 patients (24.4%) mentioned that people they lived with were aware of their use of DAT for TB treatment, while 15 (5.8%) affirmed that nobody knew.Additionally, only 11 patients (4.3%) had ever missed a dose of TB medicine.Among them, 4 (36.3%)missed 1 dose, 2 (18.2%) missed 3 doses, and 3 (27.3%)missed 5 doses.The primary reasons for missing doses were forgetfulness (n = 8, 72.7%), side effects (n = 2, 18.2%), and not wanting someone to observe them taking the drugs (n = 1, 9.1%).Following a missed dose of TB medicine, 4 patients (36.3%) were not

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Perception, accessibility and uptake of DATs contacted by a health worker, while 5 (45.5%) were contacted the next day, and 2 (18.2%) were contacted 2 days or more later.

DISCUSSION
Findings from this study show that the majority of patients owned a phone that no one else uses.All participants were satisfied with use of DATs.Only a few (4.3%) had ever taken their TB medicine without using DAT.Of these, 63.3% did not use DAT because they forgot to text medication labels and 27.6% due to network connection being poor.Limited numbers (4.3%) missed doses of TB medicine with the range of missed doses being one to five.Reason for missing the doses were majorly that they forgot to take the drugs followed by side effect and few not wanting someone to know that they take the drugs.This is expected as TB is commoner among persons of low socio-economic status.Also, network issues are common in the country.Research has previously alluded that although cellular infrastructure and mobile phone ownership are advancing globally, poor network coverage, low-quality phones, and shared phone usage remain as limitations.Importantly, a study in Peru showed that mobile phone access is lowest among the poorest patients with TB. 18 Other earlier documented reasons for missed videos were phone malfunction, uncharged battery and app malfunctions. 19The same study noted that 92% of patients reported being very satisfied with using VDOT. 19In another study, people with TB had an overall positive impression of DATs with pooled estimates between 4.0 to 4.8 out of five across categories.However, 44% of people with TB reported taking TB medications without reporting dosing via DATs and 23% reported missing a dose of medication. 20Common reasons identified in the study included problems with electricity, network coverage, and technical issues with the DAT platform.DATs were overall perceived to reduce visits to clinics, decrease cost, increase social support, and decrease workload of HCWs. 20rior study found DATs to be technically feasible nevertheless identified potential challenges to include; the impact of the technology on confidentiality, shared phone ownership, usability skills, and availability of electricity. 21Decreasing adherence has also been reported due to side effects 22 and indifference by patients in engaging with the DAT to record the dose they have taken. 23orthy of note is that this might not necessarily reflect suboptimal medication intake. 24For example, a study on whether or not the use of 99DOTS accurately represents if a dose was taken found that 99DOTS tends to underestimate adherence. 25ost participants in current study stated that the reminders they receive on their phone help them to remember to take their medicine even though that a few said that it takes them too much time to record themselves taking their TB medicine, or text 3340 for the labels every day.Also, a sizeable percentage were worried that using the DAT will make them more likely that

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Perception, accessibility and uptake of DATs others will find out that they have TB.This is supported by earlier studies.A study in southwestern Uganda, participants recounted that DAT are generally acceptable with the major feedback being perceived utility that intervention was beneficial in motivating and reminding patients to take medication, as well as enabling provision of social support. 20This implies that mobile telephones could provide alternative approaches to providing social support for TB medication adherence especially where patients do not stay close to their social supporters.
Although there is an increasing use of DATs, such as real-time monitors and SMS reminders, in TB medication adherence, research to date reports mixed results. 16Differences in findings may relate to the extent of patient involvement in technology development, context, culture, and technology exposure.Additionally, despite their potential, data supporting the impact of DATs on treatment success and mortality are limited, 26,27 and suboptimal patient engagement with various DATs for TB has been reported. 28,29revious studies in high-income 30 and low-income countries 31,32 have reported high adherence and patient satisfaction with VDOT.Equally, VDOT can overcome the limitations of in-person DOT at the patient and health system levels.For example, VDOT study has shown that the distance barrier is mostly eliminated, 33 patients have greater autonomy to choose when and where to take their medications, 33 the costs of travel are minimised and providers can support a higher number of patients, thus increasing the health system efficiency. 33n insignificant number of participants bought additional items to support the use of DAT.This should be avoided as it may hamper uptake of DATs bearing in mind that the majority of the patients are already poor.This is supported by another study that reported financial constraints as a notable limitation and proposed a potential role for financial incentives. 34

CONCLUSION
The majority of the patients own a phone, have airtime credit for internet on their phone sometimes and were satisfied with use of DATs.Almost all comply by taking their TB medicine using adherence technology and, on few occasions, did not send messages as they forgot or due to poor network connection.Limited numbers missed doses of TB with major reason because they forgot to take the drugs followed by side effect.This is in line with other previous studies.Although DATs were acceptable in a wide variety of settings, there were challenges related to the feasibility of using current DAT platforms.Implementation efforts should concentrate on ensuring access, anticipating, and addressing technical challenges, and minimising additional cost to people with TB.

TABLE 1 .
Characteristics of patients.

TABLE 2 .
Ownership, access and use of mobile phone and ancillary expenses incurred in the course of treatment.
DAT = digital adherence technology.

TABLE 3 .
Opinion on DAT.

TABLE 4 .
TB medication activities of patients and health workers' assistance/involvement.

Table 5 .
DAT use: missed doses of TB medicine and healthcare worker responses.